Management of Vascular Access in Transcatheter Aortic Valve Replacement : Part 2: Vascular Complications

The interventional cardiologist must be able to recognize and manage potential vascular complications. Iliofemoral complications are the most frequent vascular complications in transfemoral transcatheter aortic valve implantation. Small vessel dimensions, moderate or severe calcification, and center experience are the major predictors. The traditional treatment for injured arteries has been surgical reconstruction, but endovascular techniques may allow for less invasive but effective management of arterial injuries. Dissection may be treated with prolonged balloon inflation or deployment of a self-expanding or balloon-expandable stent or a surgical graft. Iliofemoral rupture is a serious complication that may lead to retroperitoneal bleeding that can be unrecognized. Rapid insertion of a dilator or sheath or an occlusive balloon is used to achieve hemostasis. Prolonged balloon inflation or implantation of a covered stent or surgical repair should then be considered. Treatment options for failed percutaneous closure include prolonged manual compression, balloon angioplasty, stent implantation, and surgery. Aortic complications are rare, but serious complications are associated with a high mortality rate, even if emergent surgery is performed. There are specific vascular complications associated with alternative access routes such as transapical and transaxillary and direct aortic access.